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POR OFFICE USE: APPLICATION' FOR SANITATION PERMIT Permit No. - ------------------ ------- - --- -------- (Complete in Duplicate} 6 -___-_--.__: This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work he des ibed. This application,is made in compliance with County Ordinance No. 549. 11 JOB ADDRESS AND CATION--- /0 7 �--- -- �--�-4 --------- Owner's Name cLs��l � ► -�' ------ Phone-------------------------------------- Address---------- 'f2en./rv.,_ -------------------------------------------------- -------- Contractor's Name.------ -- ------------------------------ ----------------- Phone Installation will serve: Residence E Apartment Hose ❑"�--Comgercial:!E]-CTrailer Court ❑ Motel ❑ Other ❑ Number of-1 I-V ing units: __/ Number of-bedF-oms-/___Number`o `baths-_�'=--L-ot size-_ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table________ ft. Character of soil to a depth of-3 feet: Sand ❑ Gravel ❑ Sandy Loam lay Loam ❑ Clayi❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,dpte__f------_,_--_____ No E] New Construction: Yes ❑ No ❑1 JFHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted(if public sewer is available within 200 feet.) Septic p Tank: Distance from nearest well------------------Distance from foundation--------------------Material_k___________________________________________ ❑ No. of compartments---t------ _ ._:_.Size--------------------------- _-Liquid dep- h-------- � Capacity----------------------- Dis � a t Il-_-„'Q_f_}Distance from foundation to nearest lot line__. .__. posa 1,Fiefd: Numbee.of 1 neseares we Length of each line___= -�_-'_.----._-Width oftrench___ :f______________________ �..y . f Ir-01 I ywT ste filterY mate , Depth of filter material_______ Total legth------ _ ------------------------- Seepage __________t________-_ See a e Pit: Dianceto nearest wel ; __._._ _Distance from foundation____________________Distance to nearest tot line__.___________-__ ❑ it Number of pits--------:-- - ------------------------Size: Diameter-------------------. _Depth__------------------------------_ Cesspool: Distance from nearest-well-----------------Distance from foundation-------------------Lining material_____________________________________. ❑ . Size: Diameter----..:- =' _``_: - ----Qepth----------------------------------------------------Liquid Capacity------------------------` 9 4_T- � __ ale. Privy: Distance from nearest well------------ `--- --------------------------- --Distance from nearest building-_----------------------------'-----_-_--. ❑ Distance to nearest lot line____J_______ _ ______________-._.___________ tom' Remodeling and/or repairing (describe):----------e5z '---=--J--------------------------------------- ------------------------------------------------------------------------------- --------------------------------- - -------- -4---------------------- ., ---------------------- ------- ----- '-------------------------------------•--•---------------------------------------------•---------------------------------------------------- ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ' = -------------------------------------------------- d/or Cantractorl (Signed) r � - r BY {Title} --------- - --- (Plot plan, showing size of lot, location of sys em in re fin wells,.buildings, etc., can be placed on reverse side). p-Y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- -- --------------- DATE__ _ _ REVIEWEDBY------------------------------------------------------------------------------------ --------------- ------------------ DATE---------------- -------------------- ------------ BUILDINGPERMIT ISSUED-------------------------------------------------------------- -------------------------------------- DATE--------------------------..........---=------------ Alterationsand/or recommendations----------------------------------------------------------------------- --------------------------• --------------•---------------------- --------------------------------------------------•-•------------------------- ---------- ---------------------------------------------- ---------- ---------------------------------:--------- - - ----------------------------------------------------------------•--------------------------------------------------------------------------------- --•-------------------------------------------------------------------- ------------•------------------------------------- ----- t, ----------------------------------------- ---- FINAL INSPECTION BY:��. s'. Y� '1 ~_- ,_ .:_.__ Date---- -----�.-- 7, s SAN JOAQUIN LOCAL HEALTH DISTRICT a� 1601 E.Haxelton Ave. 300 West>Oak-,Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracyr California ES 9 REVISED S-59 3M 3-'63 F.P.Da. • i�